Manjisthadi Lepa as Vedanasthapana in soft tissue injury with special...

[Full title: Manjisthadi Lepa as Vedanasthapana in soft tissue injury with special reference to Ankle Sprain]

ISSN: 2456-3110 ORIGINAL ARTICLE Nov-Dec 2018 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2018 | Vol. 3 | Issue 6 36 Manjisthadi Lepa as Vedanasthapana in soft tissue injury with special reference to Ankle Sprain Dr. Pallavi A. Hegde, 1 Dr. P. Hemantha Kumar 2 1 Ph.D. Scholar, 2 Guide, Dept of Ayurveda (Shalya Tantra), Tilak Maharashtra Vidyapeeth, Pune, Maharashtra, INDIA. I NTRODUCTION The incidence of trauma began from the time, existence of the fittest. Sushruta Samhita is a treatise of ancient age, which assembles surgical aspects in systematic outline [1] The rate of trauma is rising due to aggressive and excited lifestyle. When going through the classification of trauma, acute musculo- Address for correspondence: Dr. Pallavi A. Hegde Ph.D. Scholar, Dept of Ayurveda (Shalya Tantra), Tilak Maharashtra Vidyapeeth, Pune, Maharashtra, INDIA. E-mail: drpallaviah@rediffmail.com Submission Date: 05/10/2018 Accepted Date: 30/10/2018 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.3.6.6 skeletal injuries and sprains are ranked high. In 75% of ankle injuries most common is Ankle sprain. In young athletes 10-30% of sports related injuries are acute ankle trauma. Acute ankle injuries make nearly one million people consult the doctors. More than 40% of ankle sprain have the potential to cause chronic problems [2] In the United States it is estimated that 23,000 people per day, necessitate medical care for ankle sprains including athletes and non-athletes. In other form it can be said that, 1 case per 10,000 persons per day visit the physician for care [3] Most common complication of repetitive ankle injuries is post-traumatic osteoarthritis. From one of the study it was noted that post traumatic osteoarthritis of the hip, knee or ankle also fall under 12% of the overall prevalence of osteoarthritis. $3.06 billion dollars annually economic encumber is noted to solve the problem [4] A B S T R A C T Background: Demanding lifestyle has boosted the incidence of trauma/soft tissue injury. One among such conditions is sprain with site predominance as Ankle accounting for 75%. Most sprains are sports related injuries and treatment for which is PRICE (pain killers, rest, icepack, compression and elevation) in allied science. In the United States it is estimated that 23,000 people per day, necessitate medical care for ankle sprains including athletes and non-athletes. Achayra Sushruta in the context of Bhagna Chikitsa explained Manjisthadi Lepa to combat Vedana (pain). Objective of the study: To evaluate the Vedanasthapana effect of Manjisthadi Lepa in soft tissue injuries with special reference to Ankle sprain. Materials: 40 patients of Ankle sprain were selected from OPD and IPD of BVVS Ayurved Medical Hospital, Bagalkot based on the inclusive criteria. Study design: Single group, open clinical study. Method: Lepa was applied at affected site twice daily for 07 days and removed before it dried. Follow up: on 15 th , 30 th and 45 th day. Observation: Age distribution showed 40% of patients were between 20-30 years with female predominance of 67.5%. Occupation wise students ranked more. Mode of injury dominates to getting down the stairs 80% with inversion of foot 85% especially left sided majority of 82.5% having grade I injury. Interpretation and conclusion: The study showed 88.2% improvement in pain, 85.7% in tenderness, 71.8% in swelling and 100% in loss of function and discoloration respectively by a period of one week treatment. Ankle range of movements showed 100% improvement with p value <0.001. Key words: Ankle Sprain, Manjsthadi Lepa, Soft Tissue Injury, Bhagna.

Dr. Pallavi A. Hegde et.al. Manjisthadi Lepa as Vedanasthapana in soft tissue injury. ISSN: 2456-3110 ORIGINAL ARTICLE Nov-Dec 2018 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2018 | Vol. 3 | Issue 6 37 On time exact and appropriate diagnosis of ankle sprain with proper treatment, raise the incidence of normal and pain-free use of the affected ankle. With appropriate history, focused physical examination and with help of the imaging techniques (X-ray, CT, MRI) the severity of injury, pathological process, acute or chronic, can be determined [5] Ankle joint withstands 1.5 times of the body weight when one walks and upto eight times of the body weight when one runs [6] It is exposed to extreme mechanical conditions during single limb support. It has to bear the total body weight and the kinetic energy generated by the indulgence of force, during walking, running or jumping, when the foot speedily makes stroke with the floor. Ankle joint is stable joint with tibia medially and fibula laterally. The joint is strongly bound around by tibiofibular and interosseous ligaments. On the medial side is the strong deltoid ligament and laterally collateral ligaments with its three bands. The ankle joint is the only Syndesmosis fibrous joint which does have a synovial membrane [7] The stability of ankle joint is moderately depended on the ligaments, as it unstable without ligaments. Inversion or Eversion of foot is the main cause for Ankle Sprain and pain is most common complaint. This form of injury leads to either tear or stretch of one or more ligaments in the ankle joint. When compared to the sprains at different sites in body, it is most likely Ankle ligaments sprained often. Even though ankle sprain seems to be simple injury, but is most painful and hinder the routine activities of the sufferer. It is characterized by pain, swelling with or without deformity. Ankle sprains presents on either medial or lateral side, but most common being lateral sprain. Twist in ankle is frequent in sports leading to ankle pain. Apart from ankle sprain, other conditions which present ankle pain as a symptom are arthritis, gout, pseudogout and infections [8] In allied science the treatment principle is PRICE i.e pain killers, rest, ice application, compression and elevation of foot. On going through the literatures, we don’t find direct explanation of sprain with its management. Acharya Sushruta while explaining Bhagna Chikitsa in the context of Asthi-Bhagna mentioned the word “ Patanabhighatadwa ” which can be considered as Patana, Abhighata or both become the main cause for sprain, where the application of Sheeta Parisheka or Sheeta Pradeha to reduce Vedana and Shopha has been emphasized [9] Lepa is considered as Adhya Upakrama by Acharya Sushruta [10] Utility of Lepa in Asthi-Bhagna , Vrana-Chikitsa , for Jatamatra Shopha having Ugra Ruja is very well described by Acharya Sushruta [11] Importance of Lepa is highlighted by a simile as - To extinguish the fired house sprinkling of water is to be carried immediately, similar way to subside the pain application of Lepa has be to be done at its earliest [12] Research works on Snayu Vikara are very few. Efficacy of Manjisthadi Lepa on Snayu Vikara is not been conducted as per recent research review [13] Here an attempt is made to study the efficacy of Sheeta Pradeha (Manjisthadi Lepa) on Ankle Sprain O BJECTIVE OF THE STUDY To evaluate the Vedanasthapana (analgesic) effect of Manjisthadi Lepa in Ankle Sprain M ATERIALS AND M ETHODS Source of Data: Patients attending OPD and IPD of BVVS Ayurved Hospital Bagalkot, Karnataka, were selected for the study irrespective of age sex, religion and occupation Sample size: 40 patients Consent: Informed and written consent was taken from all patients Inclusion criteria 1 Patients with clinical features of Ankle Sprain. 2 Patients of first and second grade Ankle Sprain. Grade I Mild pain Mild swelling

Dr. Pallavi A. Hegde et.al. Manjisthadi Lepa as Vedanasthapana in soft tissue injury. ISSN: 2456-3110 ORIGINAL ARTICLE Nov-Dec 2018 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2018 | Vol. 3 | Issue 6 38 Mild joint stiffnes Little or no loss of function Grade II Moderate to severe pain Moderate swelling Moderate joint stiffness Moderate loss of function Exclusion criteria 1 Patients with fracture and dislocation of Ankle joint. 2 Patients with third grade Ankle Sprain Grade III Severe pain Profuse swelling Complete joint stiffness Complete loss of function Diagnostic criteria 1 Diagnosis was done based on the history of inversion or eversion of foot and clinical features like – pain, tenderness, swelling, loss of function, discoloration and joint stiffness. 2 Radiographically absence of fracture or dislocation Indredients of Manjisthadi Lepa 1. Manjistha 2. Yashtimadhu 3. Raktachandana 4. Shali Pishti 5. Shatadhauta Ghrita Method of preparation of Lepa Sukshma Churna of all the above mentioned ingredients were taken in equal quantity in a bowl along with half quantity of Shatadhauta Ghrita and Lepa is prepared by mixing it with cold water and this was applied to the patients on affected site of Ankle sprain. Intervention - Manjisthadi Lepa Selected patients were examined as per the clinical proforma prepared for the study and subjected to radiographic examination. The patients of this group underwent following procedure. The patients were advised for bed rest. Foot elevation above heart level was given. Freshly prepared Sheeta Manjisthadi Lepa was applied over the affected Ankle in the Pratiloma Gati with a thickness of Ardra Maheesha Charma (0.25 cm). The Lepa was kept in situ till cracks were noted or till the patient complained of stretching sensation, i.e. before it dried completely. In all the patients Lepa was applied twice daily and this procedure was followed for one week duration. Gradually rehabilitation was advised. Follow up study Patients were examined on initial day zero and further followed daily for one week. Then weekly once follow up for four weeks to note the changes in signs and symptoms of the patients based on the research proforma and also to note whether the relief provided by the therapy was sustained or not or whether there was any relapse Assessment Criteria Daily assessment of the patient was carried out based on gradings given to subjective and objective parameters. Subjective parameters To assess the efficacy of the trial preparation or improvement in the clinical symptoms of the disease, different signs and symptoms were arbitrarily graded on the basis of severity. The Clinical gradations of symptoms are as follows;

Dr. Pallavi A. Hegde et.al. Manjisthadi Lepa as Vedanasthapana in soft tissue injury. ISSN: 2456-3110 ORIGINAL ARTICLE Nov-Dec 2018 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2018 | Vol. 3 | Issue 6 39 1) Pain No pain 0 Localized feeling of pain only during movement 1 Localized feeling of pain during movement and at rest but not disturbing the sleep 2 Localized feeling of pain during movement and rest but disturbing the sleep 3 2) Tenderness No tenderness 0 Patient winces on deep palpation 1 Patient winces on superficial palpation 2 Patient does not allow to touch the part 3 3) Loss of function Normal function/ Normal gait 0 Can walk with effort 1 Can walk with help of support 2 Cannot walk 3 4) Discoloration No ecchymosis/discoloration 0 Ecchymosis / discoloration present 1 Objective parameters 5) Swelling Swelling was directly recorded with measuring tape in centimetres and readings were noted at the level of, above the Ankle, the mid of the Ankle and below the Ankle joint, and compared with the measurements of normal limb. Ankle movements were measured with goniometry 6) Dosiflexion Angle of 25 ° 0 Angle above 15 ° 1 Angle above 5 ° 2 7) Plantarflexion Angle of 35 ° 0 Angle above 25 ° 1 Angle above 15 ° 2 Angle above 5 ° 3 8) Adduction Normal movement 0 Mild pain (movement with pain) 1 Moderate pain (movement with difficulty) 2 Severe pain (movement not possible) 3 9) Abduction Normal movement 0 Mild pain (movement with pain) 1

Dr. Pallavi A. Hegde et.al. Manjisthadi Lepa as Vedanasthapana in soft tissue injury. ISSN: 2456-3110 ORIGINAL ARTICLE Nov-Dec 2018 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2018 | Vol. 3 | Issue 6 40 Moderate pain (movement with difficulty) 2 Severe pain (movement not possible) 3 10) Inversion Normal movement 0 Mild pain (movement with pain) 1 Moderate pain (movement with difficulty) 2 Severe pain (movement not possible) 3 11) Eversion Normal movement 0 Mild pain (movement with pain) 1 Moderate pain (movement with difficulty) 2 Severe pain (movement not possible) 3 O BSERVATIONS Table 1: Distribution of Ankle Sprain patients according to observations of parameters. Parameters Patients predominant Percentage Age 20-30 years 55% Gender Female - 27 67.5% Occupation Students - 15 37.5% Mode of injury Getting down from stairs - 32 80% Mechanism of injury Inversion - 34 85% Dominant side Left - 33 82.5% Grade Grade I - 22 55% In the series of 40 patients 55% of them belonged to age group of 20-30 years, with female predominance of 67.5%. On screening the occupation students ranked 37.5% and sustained injury mainly while getting down the steps 80% with inversion of foot 85% mainly left foot 82.5%. Taking into the Grade of injury 55% of them had Grade I and 45% with Grade II Ankle Sprain. Table 2: Statistical analysis showing the result on Clinical features after one week treatment with Manjisthadi Lepa. Symptom Mean score % of relie f S. D ( ±±±± ) S.E ( ±±±± ) ‘t’ ‘P’ BT AT Pain 1.8 7 0.2 88.2 % 0.6 7 0.1 5 11 <0.001 ** Tenderne ss 1.7 5 0.2 5 85.7 % 0.6 1 0.1 4 10 71 <0.001 ** Swelling 24 08 22 35 71.8 % 1.0 4 0.2 3 7.5 2 <0.001 ** Loss of function 1.4 0 100 % 0.5 0 0.1 1 12 73 <0.001 ** Discolora tion 0.4 0 100 % 0.5 0 0.1 1 3.6 4 <0.01* **Highly significant, *Significant, SD: Standard deviation, SE: Standard error, BT: Before treatment, AT: After treatment. Table 2 showing the percentage of improvement in the clinical features of Ankle sprain as pain by 88.2%, tenderness by 85.7%, swelling by 71.8%, loss of function by 100% and ecchymosis by 100%.

Dr. Pallavi A. Hegde et.al. M ISSN: 2456-3110 Journal of Ayurveda and Integ Table 3: Statistical analysis showing Degrees of foot movements after treatment with Manjisthadi Lepa. Foot Movement s Mean score % of reli ef S.D ( ±±±± ) S.E ( ±±±± ) BT A T Dorsiflexio n 1.5 0 100 % 0.4 4 0.0 9 Plantarflexi on 2.0 5 0 100 % 0.8 3 0.1 9 Adduction 1.1 5 0 100 % 0.4 9 0.1 1 Abduction 0.6 5 0 100 % 0.5 9 0.1 3 Inversion 1.1 5 0 100 % 0.4 9 0.1 1 Eversion 0.7 0 100 % 0.5 7 0.1 3 There was 100% result in all the moveme joint after one week of treatment. Table 4: Results of follow up after Manj application in Ankle Sprain Signs and Symptoms Mean score BT AT Pain 1.87 0 Tenderness 1.75 0 Swelling 24.08 0 Loss of function 1.44 0 Discoloration 0.4 0 Dorsiflexion 1.5 0 Plantar flexion 2.05 0 Adduction 1.15 0 Abduction 0.65 0 Inversion 1.15 0 .al. Manjisthadi Lepa as Vedanasthapana in soft ORIGINAL ARTI tegrated Medical Sciences | Nov - Dec 2018 | Vol. 3 ing results of ter one week ‘t’ ‘P’ 13.3 3 <0.001 ** 10.7 9 <0.001 ** 10.4 5 <0.001 ** 5 <0.001 ** 10.4 5 <0.001 ** 5.38 <0.001 ** ements of Ankle anjisthadi Lepa % of relief 100 100 100 100 100 100 100 100 100 100 Eversion 0.7 BT: Before treatment, AT: Afte Table 5: Total effect of Groups after one week tre Total Effect Complete remission (100% reduction in signs and sympto Marked improvement (75-99 reduction in signs and sympto Moderate improvement (50- reduction in signs and sympto Mild or No improvement (1-4 reduction in signs and sympto Or no change in signs and symptoms) Total effect of the treatme week, 75% patents had 17.5% marked and 7.5% wi Figure 1: Overall results week of treatment for Ank Overall Result - The improvement in pain, 85.7 swelling and 100% in discoloration respectively 0 10 20 30 40 50 60 70 80 75% 17.5% Overal soft tissue injury. RTICLE Nov-Dec 2018 ol. 3 | Issue 6 41 0.7 0 100 After treatment of Manjisthadi Lepa in both treatment for Ankle Sprain. Patients in number and % ptoms) 30 75% 99% ptoms) 07 17.5% -74% ptoms) 03 7.5% 49% ptoms 0 0% tment in 40 patients after one had complete improvement, with moderate improvement. ults in 20 patients after one Ankle Sprain. The study showed 88.2% 85.7% in tenderness, 71.8% in in loss of function and ively. There was marked 5% 7.5% 0 erall Effect SG

Dr. Pallavi A. Hegde et.al. Manjisthadi Lepa as Vedanasthapana in soft tissue injury. ISSN: 2456-3110 ORIGINAL ARTICLE Nov-Dec 2018 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2018 | Vol. 3 | Issue 6 42 improvement in all the parameters of Ankle Sprain with p<0.001 after one week treatment DISCUSSION Gulpha Marma (vital points) is present at the junction of Pada (foot) and Jangha (ankle). It is Rujakara Marma (painful point) and produces the symptoms as Ruja (pain), Stabdha Padata (stiffness of joints) or Khanjata (limping) when injured, [5] which are similar to the features of Ankle Sprain as pain ( Ruja ), stiffness of joint ( Stabdha Padata ), loss of function (Khanjata ) and swelling. Generally Ruja Sthala is rich of nociceptive nerve endings, which are found abundantly in ligaments, tendons, periosteum and apophyseal joints. Ankle Sprain is mainly caused by inversion (85%). Most commonly anterior talo-fibular ligament followed by calcaneo-fibular ligament. Considering the Samprapti (pathogenesis), it is the vitiated Rakta (blood), which is causing Margavarodha (obstruction) to Vata (nerve conduction) producing the Lakshanas (symptoms) after the trauma. Hence Vyadhi Viparita Chikitsa (symptom opposite treatment) is followed i.e Sheeta Pradeha (cold anointment). In the context of benifits of Pradeha , Acharya Sushruta emphasizes to use Pradeha (cold anointment) at the site of Marama Stitha Dosha (vital point seated ) . So is the present study carried based on the same principle. Mode of action Manjisthadi Lepa is a combination of 5 ingredients which together are Tridosha Shamaka . Manjistha and Yastimadhu are Vedanahara while Manjistha and Raktachandana are Raktaprasadaka . The reduction in swelling that accompanies the application of cold therapy following acute injury can be attributed to immediate vasoconstriction of the arterioles and venules, which reduces the circulation to the area and therefore reduces the extravasations of fluid into the interstitium. The major effect of cold therapy is to relieve pain. The probable mechanism involved is the stimulation of cold receptors. These receptors are present in the epidermis and are attached to medium diameter myelinated A fibers, although few connect to small diameter unmyelinated C fibers. Temperature of 25 ° C activates cold receptors, which send impulses into spinal cord through posterior root and close the pain gate. Cold also stimulates the mid brain which may release Beta Endorphins or Enkephalins into posterior horn and indirectly reduce pain by stimulation of thalamus. CONCLUSION Gulpha Marma Abhighata (ankle vital point injury) can be co-related with Ankle Sprain. Seven days application of Manjisthadi Lepa provided significant relief in the signs and symptoms of the patients of Ankle Sprain. The Manjisthadi Lepa provided better relief in pain, tenderness, ankle swelling, loss of function, dorsiflexion, abduction, inversion and eversion of the ankle joint. Complete remission of clinical features in 75% of patients after one week and 100% in the follow-up study. Lepa should be cold in potency and cold to touch when applied in acute soft tissue injury. Thus Manijsthadi Lepa can be can be used in soft tissue injury without wound to reduce the pain. REFERENCES 1 J. N. Mishra: Marma and its Management Vijnana, 5 th Edition-2005;published Chaukhamba Orientalia Varanasi; Pg 1-3,69,72,73,8 2 Jeffrey D. Tiemstra, MD department of Family Medicine University of Illinois College of Medicine, Chicago. Article Update on Acute Ankle sprains http/www.aaff/org/afp/2012/0615/p 1170.html 3 Barbara L. Braun, PT. Effect of Ankle Sprain in a General Clinic Population 6 to 18 Months After Medical Evaluation. www archfammed.com 4 Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma . Nov-Dec 2006;20(10):739- 44. [Medline].) 5 Slimmon D, Brukner P; Sports ankle injuries - assessment and management. Aust Fam Physician. 2010 Jan-Feb;39(1-2):18-22 6 Jayant Joshi and Prakash Kotwal: Essential of Orthopaedics and Applied Physiotherapy; published B. I. Churchill Livingstone Pvt Ltd-New Delhi; Pg-555

Dr. Pallavi A. Hegde et.al. Manjisthadi Lepa as Vedanasthapana in soft tissue injury. ISSN: 2456-3110 ORIGINAL ARTICLE Nov-Dec 2018 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2018 | Vol. 3 | Issue 6 43 7 Jayant Joshi and Prakash Kotwal: Essential of Orthopaedics and Applied Physiotherapy; published B. I. Churchill Livingstone Pvt Ltd-New Delhi; Pg-558. 8 www.podiatrychannel.com 9 Yadavji Trikumji Acharya; Sushruta Samhita with Nibandha Sangraha commentary of Sri Dalhanacharya, & Nyachandrika Panjika commentry of Gayadas; 7 th Edition 2002. published by Chaukhamba Orientalia Varanasi, Chikitsa Sthana 3 rd chapter-sloka 47; pg 418 10 Yadavji Trikumji Acharya; Sushruta Samhita with Nibandha Sangraha commentary of Sri Dalhanacharya, & Nyachandrika Panjika commentry of Gayadas; 7 th Edition 2002. published by Chaukhamba Orientalia Varanasi, Chikitsa Sthana, 3 rd chapter-sloka 47; pg 415 11 Yadavji Trikumji Acharya; Sushruta Samhita with Nibandha Sangraha commentary of Sri Dalhanacharya, & Nyachandrika Panjika commentry of Gayadas; 7 th Edition 2002. published by Chaukhamba Orientalia Varanasi, Sutra Sthana 18 th chapter-sloka 03; pg 84 12 Yadavji Trikumji Acharya; Sushruta Samhita with Nibandha Sangraha commentary of Sri Dalhanacharya, & Nyachandrika Panjika commentry of Gayadas; 7 th Edition 2002. published by Chaukhamba Orientalia Varanasi, Chikitsa Sthana, 1 st chapter-sloka 14; pg 396. 13 M. S. Bhagel: Research in Ayurveda, 2 nd Edition-2005, published by Mridu Ayurveda publications and sales, Jamnagar. ******************************* How to cite this article: Dr. Pallavi A. Hegde, Dr. P. Hemantha Kumar. Manjisthadi Lepa as Vedanasthapana in soft tissue injury with special reference to Ankle Sprain. J Ayurveda Integr Med Sci 2018;6:36-43. http://dx.doi.org/10.21760/jaims.3.6.6 Source of Support: Nil, Conflict of Interest: None declared.

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Sushruta-samhita, Margavarodha, Clinical feature, Mode of action, Objective of the study, Inclusion criteria, Exclusion criteria, Diagnostic criteria, Acharya Sushruta, Study design, Complete remission, Joint stiffness, Subjective parameter, Objective parameter, Tridosha shamaka, Total effect, Female predominance, Rujakara marma, Gulpha marma, Bhagna Chikitsa, Ankle Sprain, Raktaprasadaka, Loss of function, Mechanism of injury, Post-Traumatic Osteoarthritis, Soft tissue injury, Sports-related injuries.